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-� • •�•••P•C•= P•zus ay -c- a••u w the County onty on paper not less than 8 1/2 x lunchekln size' "�� t <br />L 1 41JI0 j 1 L// <br />L BURNETT COUNTY Lool <br />SBD -6398 (R0313) ZONING <br />ff <br />Industry Services Division <br />County <br />t1° -t7"_— <br />S' " � <br />D <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />t;, , <br />S � <br />P.O. Box 7162 <br />1 `� <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this fonn to the appropriate governmental unit <br />r4 <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />3D �S-e% <br />purposes in accordance with the PrivacyLaw, s. 15.04(I)(m), Stats. <br />L]avt <br />I. Application Information Please Print <br />- All Information <br />✓ov tit <br />Property Owner's Name <br />��ar^ 54) (t,11s <br />Parcel # <br />v7_a3d a_4f rs- r8 -s` <br />-� &IJ6ee, <br />Property Owner's tailing Address <br />Property Location <br />1 G ( /fSfi1, St <br />Govt. Lot <br />y, y,, Section 8 <br />t <br />City, State <br />Zip Code <br />Phone Number <br />(I,A01Y 0.1 L✓� <br />cucleone� <br />T �/ N; R / E oQC> <br />II. Type of Building (check all that apply) <br />Lot # <br />I or 2 Family Dwelling - Number of Bedrooms 3 <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />j„a <br />VC,0 /S -,g <br />,Town of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) , <br />A. <br />❑ New System <br />;0 Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Pen -nit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />F Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sQ e <br />Dispersal Area Proposed (st) <br />System Elevation <br />ys° <br />. `7 <br />Y3 <br />��`� <br />may, a 9 ell <br />Vl. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />o <br />�� v <br />New TanksExisting <br />Tanks <br />` O u <br />y y y <br />ro <br />C, U in <br />yr <br />w V n. <br />Septic or Holding Tank <br />ry 66, <br />00 <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRs Number <br />Business Phone Number <br />/2"C /C la /ci- s <br />I /.L-�/ <br />of s-�y3 <br />>iS = �'� F - 7 <br />Plumber's Address (Street, City, State, Zip Code) <br />oI 77iO .7-5'— 7 <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Pen O <br />Date Issued <br />Issuing Agent Signa e <br />❑ Owner Given Reason for Denial <br />$ <br />IX. Conditions of Ap roval/Reasons for Disapproval <br />APPR ED ECEIV� <br />n <br />-� • •�•••P•C•= P•zus ay -c- a••u w the County onty on paper not less than 8 1/2 x lunchekln size' "�� t <br />L 1 41JI0 j 1 L// <br />L BURNETT COUNTY Lool <br />SBD -6398 (R0313) ZONING <br />ff <br />